Healthcare Provider Details

I. General information

NPI: 1871331702
Provider Name (Legal Business Name): SUMMIT PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 N SENECA SPRINGS WAY # 110
STAR ID
83669-6037
US

IV. Provider business mailing address

457 S FITNESS PL STE 100
EAGLE ID
83616-6568
US

V. Phone/Fax

Practice location:
  • Phone: 208-995-2913
  • Fax: 208-995-2659
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RANDALL KEITH LANGLEY
Title or Position: PRESIDENT
Credential: PT
Phone: 208-939-3332